Glasgow Coma Scale–Centered Trauma Activation for Geriatric Ground-Level Falls: A 37-Center Cohort Study

BACKGROUND: Ground-level falls (GLFs) in older adults generate substantial trauma-center volume, yet few patients require immediate trauma-team interventions. We evaluated predictors of High-Intensity Time-Sensitive (HITS) interventions and whether Glasgow Coma Scale (GCS)-centered full trauma activation (fTA) could improve triage efficiency. STUDY DESIGN: This retrospective observational cohort study analyzed trauma registry data from adults aged 65-89 years with GLFs at 37 U.S. Level I/II trauma centers (2017-2019). The primary outcome was receipt of ≥1 HITS intervention. Mixed-effects logistic regression with hospital random intercepts and dominance analysis identified independent predictors of HITS utilization. Observed triage performance was compared with theoretical GCS-based fTA thresholds. RESULTS: Among 41,737 patients, 5% (n=2,154) received fTA; 26% received ≥1 HITS intervention, yielding 74.2% (1,598/2,154) observed overtriage. Observed undertriage was 2.3% (919/39,583). GCS ≤8 was strongly associated with HITS utilization (aOR=42.3 [35.00-54.6]) and accounted for 58.4% of total model explanatory power. In a theoretical strategy restricting fTA to GCS ≤8, fTA decreased from 5.2% (2,154/41,737) to 2.4% (934/39,016) and overtriage from 74.2% (1,598/2,154) to 39% (317/811; P<.001), while undertriage changed from 2.3% (919/39,583) to 2.4% (934/39,016; P=.52). CONCLUSIONS: These findings challenge current geriatric activation protocols by demonstrating physiologic depression-not age, comorbidities, or anticoagulation-is the dominant determinant of early trauma team-level care for GLFs. A GCS-centered activation strategy could substantially reduce fTA overtriage without significantly increasing undertriage; prospective evaluation within broader triage algorithms is warranted.